Putting a price on nurturing care
Authors: Alanna Sincovich, Zohra S Lassi
Journal: The Lancet Global Health (2023)

At the halfway mark for implementation of the Sustainable Development Agenda, progress towards achieving targets centred on child health and development has decelerated, impeding the survival and potential of many children. The Lancet Series on optimising child and adolescent health and development called for renewed efforts to nurture the health and development of all children.1Bhutta ZA Boerma T Black MM Victora CG Kruk ME Black RE Optimising child and adolescent health and development in the post-pandemic world.Lancet. 2022; 399: 1759-1761Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar To accomplish this, it is necessary to expand implementation of evidence-based interventions that address factors jeopardising optimal outcomes, spanning from pre-conception into adulthood. The cost-effectiveness analysis done alongside a cluster randomised control trial aimed at promoting early childhood development, reported by Baek and colleagues,2Baek Y Ademi Z Tran T et al.Promoting early childhood development in Viet Nam: cost-effectiveness analysis alongside a cluster-randomised trial.Lancet Glob Health. 2023; 11: e1269-e1276Summary Full Text Full Text PDF Scopus (1) Google Scholar makes significant strides in this endeavour. This economic evaluation accompanies the trial findings published by Fisher and colleagues,3Fisher J Tran T Tran H et al.Structured, multicomponent, community-based programme for women's health and infant health and development in rural Vietnam: a parallel-group cluster randomised controlled trial.Lancet Child Adolesc Health. 2023; 7: 311-325Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar which reported that a multicomponent intervention provided to women in rural Viet Nam from mid-pregnancy to 12 months postpartum positively affected children's cognitive, language, and motor development at age 2 years, relative to standard care. The economic evaluation showed that the total cost of the intervention was US$273 per child over 18 months of implementation, with recurrent costs of $58 per child. Based on recurrent costs, the incremental cost-effectiveness ratio for each increase in children's cognitive development score was $14; approximately 0·5% of Viet Nam's GDP per capita. This cost is below the benchmark of 2% GDP investment in early childhood development stipulated by the G20 initiative,4Richter LM Desmond C Behrman J et al.G20's Initiative for Early Childhood Development.Lancet. 2018; 392: 2695-2696Summary Full Text Full Text PDF PubMed Scopus (10) Google Scholar and this threshold guided authors' conclusions that the intervention was cost-effective. Before this study, several interventions had shown effectiveness in promoting early childhood development in resource-constrained settings.5Vaivada T Lassi ZS Irfan O et al.What can work and how? An overview of evidence-based interventions and delivery strategies to support health and human development from before conception to 20 years.Lancet. 2022; 399: 1810-1829Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar However, these studies have typically targeted a single mechanism to enhance children's development and have rarely been done alongside economic evaluations. A cohort study done in Jamaica showed that a combined nutrition and stimulation intervention implemented in the late 1980s yielded enduring cognitive and economic benefits into adulthood.6Gertler P Heckman JJ Pinto R et al.Effect of the Jamaica Early Childhood Stimulation Intervention on Labor Market Outcomes at Age 31. National Bureau of Economic Research, Cambridge, MA2021Crossref Google Scholar, 7Walker SP Chang SM Wright AS Pinto R Heckman JJ Grantham-McGregor SM Cognitive, psychosocial, and behaviour gains at age 31 years from the Jamaica early childhood stimulation trial.J Child Psychol Psychiatry. 2022; 63: 626-635Crossref PubMed Scopus (14) Google Scholar An intervention in Pakistan implemented from 2009 to 2012 showed that integrated nutrition and early stimulation components from birth to age 2 years was more cost-effective in improving child development outcomes than implementing these interventions individually.8Gowani S Yousafzai AK Armstrong R Bhutta ZA Cost effectiveness of responsive stimulation and nutrition interventions on early child development outcomes in Pakistan.Ann N Y Acad Sci. 2014; 1308: 149-161Crossref PubMed Scopus (32) Google Scholar The intervention implemented in rural Viet Nam, termed Learning Clubs, is unique relative to previous trials because it targeted factors encompassing all five components of the Nurturing Care Framework9WHONurturing care for early childhood development: a framework for helping children survive and thrive to transform health and human potential. World Health Organization, Geneva2018Google Scholar (good health, adequate nutrition, responsive caregiving, opportunities for early learning, and safety and security) to address multiple risks to early childhood development simultaneously. In addition to the typical elements observed in previous interventions, this approach included components centred on maternal nutrition and maternal mental health, and gender-based risks, including intimate partner violence. Furthermore, the intervention is the only one that has been implemented antenatally to improve pregnancy outcomes until children reached age 12 months. Although these additional components incurred extra start-up and recurrent costs, the intervention remained cost-effective when considering the observed gains in children's development. Overall, Baek and colleagues' study2Baek Y Ademi Z Tran T et al.Promoting early childhood development in Viet Nam: cost-effectiveness analysis alongside a cluster-randomised trial.Lancet Glob Health. 2023; 11: e1269-e1276Summary Full Text Full Text PDF Scopus (1) Google Scholar provides the first evidence of cost-effectiveness for a multicomponent approach that comprehensively strengthens nurturing care to support early childhood development in a low-income and middle-income country setting, from pregnancy through infancy. These findings provide the necessary evidence to advocate for the value of investing in the scale-up of the Learning Club intervention in Viet Nam and similar settings. During the scale-up process, it is important to consider universal versus targeted implementation. The cost-effectiveness analysis in this study was on the basis of trial results that employed a population approach (ie, all women were eligible to participate), whereas many previous trials focused on specific sub-groups (eg, the Jamaica study targeted children who were stunted exclusively). Future implementation of Learning Clubs could explore child development and economic outcomes according to different socioeconomic groups or families experiencing varying degrees of risk factors that threaten early childhood development. Researchers might also explore the dose of the intervention required for positive impacts and cost-effectiveness. Findings from such investigations would provide further guidance on the most cost-effective intervention delivery strategies. Longitudinal follow-up of the intervention cohort of children should be prioritised to investigate long-term effects on child development and economic outcomes. Evidence of enduring effects achieved with a small investment would further strengthen the case for scale-up. Although the current study could not comprehensively assess the cost-effectiveness across various child development outcomes (ie, cognitive, language, and motor) due to measurement limitations, future assessments should employ multidimensional composite measures aligned with the Sustainable Development Agenda.10UN Children's FundThe Early Childhood Development Index 2030: a new measure of early childhood development. UNICEF, New York, NY2023Google Scholar This measurement will facilitate interpretation of findings, comparison of cost-effectiveness across interventions, studies or countries, and ultimately optimise resource allocation to maximise the benefits for early childhood development. We declare no competing interests. Promoting early childhood development in Viet Nam: cost-effectiveness analysis alongside a cluster-randomised trialThe intervention was cost-effective: the ICER per child cognitive development score gained was 0·5% of Viet Nam's gross domestic product per capita, alongside other benefits in language and motor development. This finding supports the scaling up of this intervention in similar socioeconomic settings. Full-Text PDF Open Access